Joint Standing Committee on Health and Human Services

Final Report to the

Joint Standing Committee on Health and Human Services

Resolve 2011, Chapter 71 (LD 1461)

Prepared by:

Maine Department of Health and Human Services

March, 2012

Maine Department of Health and Human Services

Final Report to Maine Legislature

Resolve 2011, Chapter 71 (LD 1461)

Resolve 2011, chapter 71 (LD 1461) directs the Department of Health and Human Services (DHHS) to adopt a plan related to a report prepared by DHHS for the 124th Legislature entitled “Services for Elders and Other Adults Who Need Long Term Home and Community Based Care” dated January 20, 2010 (known as the “Lean Implementation Plan”).

The specific initiatives as listed in the legislation that are incorporated into an action plan include, but are not limited to:

1. Consolidating two existing waivers for elders and adults with disabilities (Section 19 and Section 22, MaineCare Benefits Manual, Chapter II);

Implementation: July 1, 2013

2. Consolidating two MaineCare State Plan personal care programs (Section 12 and Section 96 of the MaineCare Benefits Manual, Chapter II);

Implementation: October 1, 2012

3. Consolidating two state-funded programs, one managed by the Office of Elder Services (OES) and the other self-directed program managed by the Office of Adults with Cognitive and Physical Disabilities (OACPDS) and including the state funded Independent Services and Supports (ISS/Homemaker) as part of that consolidation;

Implementation: July 1, 2013

4. Developing a long-term care services statewide plan that ensures access to care in the least restrictive environment;

Implementation: Ongoing

5. Maximizing federal opportunities available through the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services;

Implementation: Ongoing

6. Consolidating the 3 existing consumer-directed service models into a single uniform self-directed model;

Implementation: October 1, 2012

7. Maximizing individualization and flexibility of the plan of care to ensure appropriate and timely services are provided, including, but not limited to, allowing a care coordinator to make adjustments within a plan of care without requiring a new assessment as long as the net adjustment remains below the maximum value under the consumer's level of care;

Implementation: Ongoing

8. Improving value and respect for direct care workers through initiatives that include, but are not limited to, creating strategy and standards for ensuring workforce training for all persons accountable to the long-term care system and exploring the feasibility of equalizing hourly reimbursement rates across the direct care worker continuum; and

Implementation: Ongoing, with implementation of a pilot training program April 2012

9. Designing and establishing an effective quality management strategy across funding streams and population groups to ensure a high-quality long-term care service system.

Implementation: Ongoing

This work is to be accomplished within the limits of available resources.

BACKGROUND

The work being done pursuant to this legislation is occurring at the same time as other significant changes in the overall delivery system for long term services. This includes the Department’s need to review its current reimbursement of Private Non Medical Institutions (PNMIs) in response to questions raised by the Centers for Medicare and Medicaid (CMS). In addition, implementation of this bill needs to be considered in light of PL 11, Chapter 422 (LD 683), which, among other things, proposes that all long term care services provided directly or indirectly under the MaineCare program or other state-funded programs be combined into one program with a single set of rules, coordinated criteria for assessment and qualifications and a single budget. LD 683 is attached as an appendix to this report.

Implementation has been staged to provide the least disruption to members currently receiving services on these programs. DHHS will meet with stakeholders to review the implementation plan set forth in this report. It is possible that some of the implementation on the consolidation of programs will become part of larger implementation changes related to the review of PNMI reimbursement issues and the potential for changes in the eligibility criteria for institutional level of care.

These initiatives will be discussed in the order that they appear in the legislation.

INITIATIVES 1-3

Consolidating two existing waivers for elders and adults with disabilities (Section 19 and Section 22, MaineCare Benefits Manual, Chapter II).

Consolidating two MaineCare State Plan personal care programs (Section 12 and Section 96 of the MaineCare Benefits Manual, Chapter II).

Consolidating two state-funded programs, one managed by the Office of Elder Services (OES) and the other self-directed program managed by the Office of Adults with Cognitive and Physical Disabilities (OACPDS) and including the state funded Independent Services and Supports (ISS/Homemaker) as part of that consolidation.

Initiatives 1 through 3 of this bill address consolidation of several different programs providing long term care services and supports, some of which are managed though the Office of Elder Services and others through the Office of Adults with Cognitive and Disabilities. A brief summary of these programs is attached as a separate document to this report.

Based on previous stakeholder group forums, the articulated goals of this consolidation are:

· Combining multiple existing programs into fewer programs to promote equity while facilitating portability among program choices and living arrangements and optimizing service use by the person in need of services.

· Creating greater equity across long-term home-based programs in terms of financial eligibility requirements, types and amounts of services available, rates of reimbursement and wages paid to direct care workers.

· Designing MaineCare-funded waiver and state plan programs and state-funded programs to include both agency-provided and self-directed services.

· Potentially identifying opportunities for inclusion of independent support services (i.e. homemaker/IADL activities) as a MaineCare-funded service.

The Department has reviewed the current rules to identify inconsistencies in financial eligibility, functional eligibility, covered services, non-covered services and limits, reimbursement and other program requirements. As part of that review, the more significant differences have been identified. In order to accomplish these consolidations within existing resources, generally the more restrictive provisions are being adopted unless cost neutrality can otherwise be addressed and maintained.

In order to facilitate this consolidation in the least disruptive manner to consumers and providers, the program consolidations will be staged, beginning with the State Plan Medicaid services (Section 96 and Section 12). In contrast to the waivers and the state funded programs, the State Plan Medicaid programs have fewer covered services and are not capped in terms of number of eligible members who may participate.

Section 96 includes personal care and nursing services for adults. The personal care component for adults under Section 96 will be separated from the nursing benefit and transferred to Section 12 (self-directed personal care). Section 12 will no longer be limited to self-direction. This results in a stand alone personal care benefit for Medicaid State Plan service. If a member receiving personal care under the consolidated Section 12 requires nursing services, those will be accessed through Section 96, as is done now.

Implementation Date: October 1, 2012 contingent upon ability to file State Plan Amendment with CMS.

The two home and community based waivers (Section 19 and Section 22) require that individuals meet nursing facility level of care. These waivers may be affected by changes being considered to address the PNMI reimbursement relating to potential changes in nursing facility eligibility.

The most significant challenge to merging Section 22 with Section 19 relates to the cost cap for the programs. As part of the federal cost neutrality provisions, Section 19 is based on the average monthly nursing facility care cost. Section 22 has a cost neutrality provision that is based on a blended cost of nursing facility and rehabilitation hospitalization. The current cap for Section 22 waiver is 86.25 hours per week of personal care services; the current cap for Section 19 waiver is $4,341, which translates to a maximum of 64.5 hours of personal care services per week. Over 40% of members on Section 22 receive more than the current Section 19 cap. In order to maintain cost neutrality and merge these programs within existing resources, adoption of the more restrictive Section 19 cost cap will need to be considered.

As part of the work on this bill, the Department is exploring the different procedural options for combining programs, particularly the two home and community based waivers. Although Maine has combined two waivers in the past, those waivers were almost identical in terms of eligibility requirements, covered services and cost caps. Based on this history, a likely approach will be to absorb one waiver into the other, rather than create a new waiver.

Implementation Date: July 1, 2013 contingent on approval by CMS.

There are three state funded programs required to be merged under this legislation: OES Home Based Care, OES ISS/Homemaker and OACPDS self-directed services. There are currently three different agencies administering these services under contract with DHHS: EIM (OES Home Based Care); Alpha One (OACPDS self-directed) and Catholic Charities of Maine (ISS/Homemaker). The funding accounts currently sit in two different DHHS offices (OES and OACPDS).

Financial eligibility requirements will be added to the OACPDS self-directed program and co-pay requirements between the programs will be consistent. OES Section 63 co-payment calculation allows a $15,000 deduction in calculating the co-payment amount whereas OACPDS Chapter 11 allows a $30,000 deduction in co-payment calculation. In addition, levels of care will be added to the OACPDS self-directed program. Based on FY 2010 service plans it is expected that approximately 26% of participants on the OACPDS self-directed program would experience reductions in services.

The ISS/Homemaker program will be consolidated as a separate level of service delivery.

Implementation will be timed to correspond with the State fiscal year in order to accomplish consolidation of accounts, RFP processes and contract start dates.

Implementation Date: July 1, 2013

INITIATIVE 4-5

Developing a long-term care services statewide plan that ensures access to care in the least restrictive environment.

Maximizing federal opportunities available through the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services.

Initiative 4 directs DHHS to develop a plan to ensure access to care in the least restrictive environment and maximize federal funding. Much of this work is being encompassed within the current discussions that are ongoing regarding Maine’s Private Non-Medical Institutions (PNMIs) and other fiscal considerations.

DHHS has pursued and obtained federal grant funding to implement Money Follows the Person (known in Maine as Homeward Bound). This is a rebalancing grant aimed at transitioning MaineCare eligible residents from nursing homes back into the community. This grant is expected to run through 2016. In December 2011, Maine was awarded supplemental funds to complement the transition work under Money Follows the Person program through the Aging and Disability Resource Centers and other community partners.

INITIATIVE 6

Consolidating the 3 existing consumer-directed service models into a single uniform self-directed model.

This initiative is also relevant to LD 683 and changes if any are likely to be developed as part of that process.

Some of the programs included in this initiative are exclusively for people who choose to self-direct their personal care services (Section 12, Section 22 and OACPDS Chapter 11). An individual must have cognitive capacity in order to be eligible for these programs. These programs currently have Alpha One as the available service coordination agency. The other programs involved in this initiative offer a choice of either traditional agency or self direction, referred to as the Family Provider Services Option (FPSO). These programs currently have EIM as the available service coordination agency.

The intent of designing one model of self-direction includes:

· Creating a single model of self-direction based on best practices to be incorporated into all home- and community-based services.

· Developing a single skills training curriculum for people participating in self-direction.

· Including and consistently defining surrogacy in all self-directed programs.

· Recognizing and maximizing elements of self-direction even for people who choose to have an agency deliver services.

Rules will be adopted adding the use of a representative to Section 12, Section 22 and OACPDS Chapter 11, which will allow an individual other than the member to direct and manage personal care services. Requirements around background checks, employment prohibitions and other processes will be made consistent across programs.

Implementation Date: October 1, 2012

INITIATIVE 7

Maximizing individualization and flexibility of plan of care to ensure that appropriate and timely services are provided, including, but not limited to, allowing a care coordinator to make adjustments within a plan of care without requiring a new assessment as long as the net adjustment remains below the maximum value under the consumer's level of care.

This initiative is also relevant to LD 683 and changes if any are likely to be developed as part of that process.

In addition, under some of the current program rules a care coordinator has the authority to adjust the frequency of services in the plan of care in the event a participant experiences a change in the need for services. In the event a member experiences an emergency or acute episode, the care coordinator may increase the plan of care up to fifteen percent of the authorized care plan amount, provided it does not exceed the monthly program cap. If the need extends beyond two weeks, a referral is made for another assessment to authorize the service for ongoing need. This type of flexibility would be made available under the merged programs developed under Initiatives 1-3.

INITIATIVE 8

Improving value and respect for direct care workers through initiatives that include, but are not limited to, creating strategy and standards for ensuring workforce training for all persons accountable to the long-term care system and exploring the feasibility of equalizing hourly reimbursement rates across the direct care worker continuum.

Maine was one of six states awarded a grant through the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) to develop and implement a competency-based curriculum and coordinated training and credentialing system for direct care workers. This grant is known as the Maine Direct Service Worker Training Grant. The demonstration is to develop and pilot core curriculum for three entry level direct care worker positions: Personal Support Specialists; Direct Support Professionals; and Mental Health Rehabilitations Technicians I. The pilot training of the new competency-based core curriculum and the PSS specialty module is scheduled to begin in April 2012. The pilot will offer face-to-face training at 6 locations across the state. The goal of this grant is to establish a sustainable delivery system that creates improved career ladders or lattices for direct care workers. The effort is intended to establish a framework for a comprehensive training system responsive to the changing needs of the population of individuals needing long term services and supports.